Continuing Education Activity

Ginger root is a plant-based spice used in the personal or professional treatment of medical conditions ranging from gastrointestinal infections to cancer. This spice originates from the root of the Zingiber officinale plant. Despite the advantages, ginger may cause adverse effects in some individuals, such as gastrointestinal discomfort, heartburn, and allergic reactions. These potential adverse effects must be considered, particularly when recommending ginger for therapeutic use. As current studies clarify, the mechanisms and effects of ginger, the role of ginger in promoting overall well-being, and disease prevention are increasingly substantiated, making ginger root a valuable component of integrative health practices.

This activity reviews the history, nutritional properties, health benefits, mechanism of action, adverse effects, interactions, and the role of ginger root as a valuable herbal nutraceutical. Clinicians should be well-versed in ginger's nutritional properties and clinical applications when integrating plant-based treatments. Understanding the scientific basis of the health benefits of ginger enables an informed and evidence-based approach to lifestyle medicine.

Objectives:

• Identify the recommended dose of ginger root for either personal or professional use.

• Evaluate the health benefits of ginger root based on current evidence-based guidelines.

• Assess the mechanism of action of ginger root in the context of a patient history's and physical examination.

• Implement interprofessional collaboration to screen for potential contraindications before recommending ginger root.

Indications

Ginger root has gained global popularity recently and is mentioned in traditional Ayurvedic and Chinese medical literature. Southeast Asian countries are the largest producers of this root. The name ginger originates from the ancient Sanskrit word srngaveram ("horn root"). The root originates from Zingiber officinale, a tropical plant with green-purple flowers and a fragrant stem known as a rhizome. Indians and Chinese are believed to have used this ginger as a tonic for thousands of years to treat illness.[1][2] 

Ginger root belongs to a family of roots that includes turmeric and cardamom. More than 1300 distinct species of ginger root plants exist. The strong aroma and flavor are derived from ketones known as gingerols, a primary root component. Ginger root is rich in micronutrients such as vitamin C, B6, magnesium, potassium, copper, manganese, fiber, and water. In addition, it is high in phytochemicals and polyphenols. Gingerols, shogaols, and paradols are the 3 major active components derived from terpenes found in ginger. The recommended daily serving size of ginger powder ranges from 170 mg to 1 g. A primary metabolite of gingerol is (S)-[6]-gingerol-4’-0-β-glucuronide. Ginger and its metabolites appear to accumulate in the gastrointestinal tract and exert their effects by relieving pain through anti-inflammatory effects, soothing the digestive system through carminative effects, and alleviating nausea. Recently, research has focused on the mechanism of ginger's action and its various components. The American College of Obstetricians and Gynecologists states that ginger can help reduce nausea during pregnancy but does not significantly reduce vomiting.[3]

According to meta-analysis, ginger supplementation significantly reduces alanine aminotransferase and insulin resistance in nonalcoholic fatty liver disease. Still, ginger does not substantially impact aspartate aminotransferase, cholesterol, low-density lipoprotein, or body mass index. Further research is required to confirm these findings. A systematic review and meta-analysis revealed that ginger significantly reduces pain and inflammation in knee osteoarthritis. Three studies involving 166 patients showed that ginger supplementation had a favorable impact compared to placebo. The American Academy of Orthopaedic Surgeons Clinical Practice Guideline on the Management of Osteoarthritis of the Knee (OA) acknowledges the possibility of ginger extract demonstrating analgesic and functional benefits in patients diagnosed with mild-to-moderate knee OA. Nevertheless, the current evidence regarding the efficacy of the ginger extract in this context exhibits inconsistency and limitations, necessitating further well-designed, randomized controlled trials.[4][5][6]

The results of a randomized controlled trial compared ginger extract to loratadine for allergic rhinitis. Both ginger extract to loratadine showed significant reductions in total nasal symptom scores. These findings suggest Zingiber officinale extract as a potential alternative for allergic rhinitis treatment. Studies have revealed the promising preventative properties against chronic diseases, such as hypertension and congestive heart disease, and their contribution to improving immune system action. A study showed that increasing ginger intake by 1 g per day based on a proper diet could provide such preventative benefits. The health benefits of ginger include antibacterial, viral, antioxidant, anti-inflammatory, antinausea, and anticancer properties.[7][8]

Mechanism of Action

The exact mechanism is not yet elucidated, but research has shown that several active compounds in ginger have biological activity.

• Gingerol and gingerol-related compounds: These compounds have Antioxidant and antitumor properties inducing apoptosis and genetic modulation, anti-inflammatory and analgesic effects, and antimicrobial and hepatoprotective properties.
• Zingerone: This compound exhibits antioxidant, anti-inflammatory, and antibacterial properties.
• Shogaol: This compound demonstrates antioxidant, anti-inflammatory, and anti-cancerous properties by inhibiting cell invasion, decreasing matrix metalloproteinase-9 expression, and increasing anti-proliferation properties.
• Paradol: This compound is known for its antioxidant, anti-cancerous, and antimicrobial properties.
• Zingerone: This compound has antioxidant, anti-inflammatory, and antibacterial properties.
• 1-Dehydro-10-ginger-dione: This compound is involved in the modulation of inflammatory genes.
• Ginger flavonoids: This compound possesses antioxidant activity.
• Terpenoids: This compound induces apoptosis through the activation of p53.

Microbes are essential to the human body and gut, keeping us healthy. However, foreign microbes can invade the body and cause illnesses, such as the flu. Evidence suggests that harmful microbes can contribute to the formation of chronic conditions, such as cancer and coronary heart disease. As pathogens gain resistance to drugs, antibiotics and vaccines can become ineffective. Ginger is vital as an antimicrobial agent. Several active components are effective against Escherichia coli, Salmonella typhi, Bacillus subtilis, Candida albicans, Mycobacterium avium, and M tuberculosis.

Antioxidants aid in eliminating free radicals from the body and mitigating oxidative stress. When reactive oxygen species surpass the body's antioxidative defenses, this process can lead to oxidative stress. Long-term exposure can lead to many chronic diseases, such as rheumatoid arthritis, post-ischemic perfusion injury, myocardial infarction, chronic inflammation, and cancer. Ginger is a source of numerous antioxidants in reducing lipid oxidation and reactive oxygen species formation. Studies have shown that the active components of ginger root are used to scavenge superoxide anion and hydroxyl radicals and inhibit lipid peroxidation in vivo.

Inflammation is an important immune response mechanism mediated through interleukin-1, tumor necrosis factor, and anti-inflammatory cytokines. Although nonsteroidal anti-inflammatory drugs are commonly used to treat inflammation, medicinal plants are of interest. In vivo studies have demonstrated the ability to suppress proinflammatory cytokines and downregulate the induction of inflammatory genes. The exact mechanism by which ginger affects nausea and vomiting is unclear, but recent studies reveal that active compounds such as gingerols, shogaols, and diterpenoids possess antiserotonergic and 5-HT3 receptor antagonistic effects, which are known to provide nausea relief.

Unregulated cell growth and tumor development are complex processes involving many genetic and metabolic alterations. Medicinal plants have long been studied for chronic disease management. The active compounds control tumor development by regulating tumor suppressor genes, induction of apoptosis, and inactivating vascular endothelial growth factor signaling. Current studies demonstrate the ability of 6-gingerols to suppress hyperproliferation and inflammatory processes leading to carcinogenesis, angiogenesis, and metastasis. Ginger is effective against gastrointestinal cancers such as gastric, cholangiocarcinoma, liver, pancreatic, and colorectal cancers.[9][10][11][12][13][14] 

Pharmacokinetics

Absorption: In a study, the ginger extract was administered orally in 250 mg capsules. After oral ingestion, gingerols are absorbed from the gastrointestinal tract into the systemic circulation. A recent study suggests measurable plasma concentrations post-dose, indicating systemic absorption.

Distribution: Gingerol compounds exhibit low protein binding. Distribution into tissues, including colon mucosa (biopsy specimens), was indicated, suggesting wide tissue distribution.

Metabolism: Gingerols undergo extensive metabolism in the liver through phase I metabolism (hydroxylation and oxidation) and phase II metabolism conjugation (glucuronidation and sulfation).

Elimination: Free gingerols are primarily eliminated through urine and feces. After enzymatic hydrolysis, glucose and sulfate conjugates are excreted mainly through urine and feces. Free 10-gingerol had a terminal half-life of approximately 2.1 hours.

Administration

Ginger root is a plant-based food that can be consumed in various ways. This spice is commonly used in healthy breakfast items, such as oatmeal and chia seed puddings; as a spice in Indian or Asian curries and cuisine; in soups; in salad dressings; in herbal tea as crushed or minced root; in powdered form as a supplement; in juices or smoothies to flavor the beverages; in baking; or as the hard candy form for the common cold and sore throat. The recommended serving is 1 tablespoon of ground ginger or two-thirds cup of freshly ground ginger.

The most common edible form of ginger root is yellow or beige. Methods of consuming ginger for a healthy lifestyle include whole, crushed, or minced in herbal tea, powdered as a supplement, juice as a flavor, or crystallized as candy for the common cold and sore throat. Ginger pills are prepared by adding fresh ginger juice to ginger powder and blending in a mortar and pestle; this mixture can be rolled into pills when dried. The proportion of juice to powder is approximately 4 to 1. Two tablets are recommended 3 times daily. The usual dose of ginger is up to 1000 mg of dried powdered extract daily.[2][15]

Specific Patient Populations

Hepatic impairment: The American Association for the Study of Liver Diseases acknowledges that nausea is a common symptom experienced by patients with cirrhosis. Research suggests that ginger may be beneficial in alleviating nausea in this patient population.

Renal impairment: Kidney Supportive Care adopts principles from palliative medicine to manage symptoms and improve the quality of life in patients with chronic kidney disease. This approach aligns with the potential benefits of ginger for alleviating nausea and dry retching.

Pregnancy considerations: As mentioned above, ginger can be used for nausea and vomiting during pregnancy.

Breastfeeding considerations: Existing data on ginger as a galactagogue for breastfeeding mothers are limited. Although some studies suggest a potential increase in milk supply, the evidence remains inconclusive. Furthermore, well-designed investigations are necessary to definitively assess ginger's safety and efficacy for lactating mothers and their infants. Caution is recommended when considering the use of ginger supplements during lactation. Potential variability in ingredient composition and the possibility of interactions with other medications necessitate consultation with a clinician before utilizing such supplements.

Pediatric patients: A randomized controlled trial was conducted to assess the antiemetic effect of ginger in reducing vomiting episodes associated with acute gastroenteritis in children. Intention-to-treat analysis revealed a significant reduction in vomiting in the ginger group compared to the control group. Further research is required.

Older patients: Research indicates that ginger possesses antioxidant, anti-inflammatory, anticancer, antimicrobial, and significant antiviral properties, highlighting its potential role in preventing aging. However, ginger should be used cautiously in patients prescribed antiplatelet or anticoagulant medications.[3][16][17][18][19][20]

Adverse Effects

The United States Food and Drug Administration considers ginger root safe, and a daily approved intake of up to 4 g is deemed safe. However, higher doses may lead to gastrointestinal discomfort, allergic reactions, prolonged preexisting bleeding, central nervous system depression, and arrhythmia. Studies have shown that ingestion of more than 6 g of ginger root can exacerbate gastrointestinal disturbances, such as gastrointestinal reflux, heartburn, and diarrhea. This spice can lower blood pressure and has been shown to cause arrhythmia in a small number of cases. Increasing bile acid secretion can aggravate gallstone formation.[21]

Drug-Herb Interactions

• Ginger can increase the anticoagulant effect of warfarin, possibly leading to warfarin toxicity and bleeding.
• Ginger may inhibit platelet aggregation. Consequently, ginger should be used with caution in patients prescribed antiplatelet medications to avoid an increased risk of bleeding.
• Ginger can increase the risk of hypoglycemia; therefore, it should be used with caution in patients prescribed oral hypoglycemic agents.[22][23][24][25][26]

Contraindications

A case report highlights the rare occurrence of adult-onset anaphylaxis caused by ginger.

Monitoring

If adverse effects are reported, minimizing ginger intake to below 4 g/d or discontinuation is recommended.

Toxicity

Signs and Symptoms of Overdose

In high doses, ginger root can exacerbate gastrointestinal disturbances such as reflux and diarrhea. As mentioned above, adverse effects can potentially cause warfarin toxicity, potentiating the drug's anticoagulant properties and leading to bleeding. The ginger root can lower blood pressure and cause arrhythmia in a small number of cases. Increased bile acid secretion can aggravate gallstone formation.[27]

Management of Overdose

There is no antidote available for ginger. In rare cases of poisoning, supportive care should be provided, and a poison control center (1-800-222-1222) should be consulted.

Enhancing Healthcare Team Outcomes

Defining health outcomes following the delivery of an herbal remedy such as ginger root requires an interprofessional team, including pharmacists, primary care clinicians, and nurses. The dosage should be optimized to reap the benefits of a natural herb. Factors such as age, sex, preexisting conditions, and diet can influence the remedial characteristics of ginger root for different cohorts.

For example, if a patient takes ginger root as a daily antioxidant to alleviate joint inflammation pain, their healthcare team should monitor health improvements or adverse effects. The treating clinician should actively assess signs of adverse effects such as gastrointestinal reflux, heartburn, or diarrhea and collaborate with a pharmacist to optimize dosing as needed.

This holistic approach provides an evidence-based method of utilizing ginger root as a supplement in lifestyle medicine. By employing evidence-based practices and ongoing monitoring, healthcare providers can enhance patient care outcomes while managing the use of ginger root as a safe and beneficial herbal supplement.